RE 1-22 Flashcards
What separates the upper and lower airway?
cricoid cartilage
Upper airway?
nose, mouth, pharynx, hypopharynx, larynx
Lower airway?
trachea, bronchi, bronchioles, terminal bronchioles, respiratory bronchioles, alveoli
The auditory (eustachian) tubes and the adenoids are found in what part of the airway?
nasopharynx
efferent response through the vagus nerve results in what?
gag reflex-the muscles of the parynx elevate and constrict
Why is the recurrent laryngeal nerve named as such?
because it loops around other structures
The right RLN loops around what structure?
brachiocephalic artery
The left RLN loops around what structure?
the aorta
Traction on the RLN can lead to what
nerve injury, hoarseness
Traction on the RLN may be caused by what pathologic conditions?
Mitral stenosis, Disecting aortic arch aneurysms
Acute RLN may progress to what?
respiratory distress, death
Patients with chronic bilateral RLN injury may sound how?
gruff or husky speach
Injury to what nerve is least likely to cause respiratory distress
SLN
4 functions of the larynx
- protection to the lower airway from aspiration
- patency btw the hypopharynx & trachea
- protective gag and cough reflexes
- phonation
What connect the thryoid cartilage to the hyoid bone?
thryhyoid fascia and muscles of the larynx
What type of cartilage is the epiglottis?
single leaf like
The space between the inferior edge of the epiglottis and the true vocal cords is known as what?
inferior vallecula
The space between the epiglottis and the base of the tongue is known as what?
superior vallecula
Intrinsic muscles of the larynx control ?
tension of the vocal cords
opening and closing of the glottis
Extrinsic muscles of the larynx control
connect the larynx, hyoid bone, and neighboring structures
adjust the position of the trachea during phonation, breathing, and swallowing
Muscles that elevate the larynx?
stylohyoid digastric mylohyoid genihyoid stylopharyngeus thyrohyoid
Muscles that depress the larynx?
omohyoid
sternohyoid
sternothryoid
Parasympathetic innervation of the tracheobronchial trees is provided by?
Vagus nerve
Sympathetic innervation of the tracheobronchial trees is provided by?
1-5 thoracic ganglia
The posterior side of the trachea is membranous for what reason?
to accomodate the esophagus during swalloing
The cartilaginous rings continue until the bronchi reach?
- 6-0.8 mm in size
* cartilage disappears and bronchi are termed bronchioles
The point at which the cartilage disappears and the bronchi begin is termed?
bronchioles
What is the function of the bronchi
provide humidification and warming of inspired air
True or false-individual airway assessment is an adequate predictor of airway difficulty.
False-individual = poor,
Use of Mult airway assessments = good
Murphy & Walls described the four dimensions of difficulty, what are they?
- BMV
- DL w/ direct tracheal intubation
- SGA
- Invasive airway placement
History of difficult airway is a sign of what?
current difficulty history
If unable to BMV after OPA placement what is another technique to ventilation the patient?
two handed BMV
What is the incidence of impossible BMV
0.15%
Signs of inadequate ventilation during BMV
- minimal to no chest rise
- inadequate or deficient exhaled CO2
- reduced/absent breath sounds
- decreasing 02 sat ,92%
Hallmarks signs of upper airway obstruction in unanesthetized patient?
hoarse or muffled voice
difficulty swallowing secretions
stridor
dyspnea
What are two ominous signs of respiratory obstruction that indicate a 50% decrease in airway circumference from normal or a diameter reduced to 4.5 mm or less?
stridor and dyspnea
Hallmarks signs of lower airway obstruction in unanesthetized patient?
high peak airway pressures
low tidal volumes
impaired ventilation
Patients w/ OSA may be challenging when performing what airway maneuver?
BMV
What makes patients who are pregnant difficult to ventilate?
gravid uterus compressing the lungs creates elevated airway resistance.
Examples of upper airway obstruction?
trauma, burns, congenital, abscess, ludwigs angina, OSA, tongue, angio edema, foreign body, epiglottitis, laryngospasm
Examples of lower airway obstruction
angioedema, ARDS, COPD, asthma, bronchospasm, pulmonary edema, obesity, prego
DTI
direct tracheal intubation
- process of placing ETT into the trachea
DL = process of airway instrumentation with laryngoscope to acquire a direct line of site with the laryngeal opening
What is the incidence of difficult tracheal intubation?
1.5-8.5%
What is the incidence of failed tracheal intubation?
0.3-0.5%
What two techniques most accurately predict difficult intubation?
Mallampati & TMD
What assessments best predict difficult laryngoscopy?
Mallampati, TMD, interincissor gap
What position should the patient be in when Mallampati is being performed?
sitting upright, extend the neck, open the mouth as much as possible, and protrude the tongue and avoid phonation
What is the incidence of visualizaiton of any part of the epiglottis on mouth opening?
1.2%
Mallampiti classification, decreased TMD, and limited interincisor opening are strong predictors of?
Difficult larygoscopy and intubation troubles
Cormack and Lehane III and IV correlate with what?
difficult intubation
TMD is a predictor of what?
the space in which the tongue can be displaced during DL to improve the direct line of site with the glottic opening
What is mandibular hypoplasia?
Condition in which the tongue does not fit into the thyromental space.
True or false-The greater the TMD the easier the intubation
False-TMD greater than 9 cm may also indicate a potentially difficult airway d/t large hypopharyngeal tongue, caudal larynx, and longer mandibulohyoid distance (MHD)
What does MHD measure?
the distace form the angle of the mandible to the hyoid bone (usually via radiograph)
Long TMD and MHD may indicate what regarding glottic opening
caudal
In assessing the position of the larynx with the 3-3-2 model, more than two fingerbreadths would inidcate the larynx position is? less than two fingerbreadths would indicate?
more than two -larynx may be positioned down the neck
less than two - larynx tucked under the base of the tongue, anterior larynx
Normal SMD =?cm
> 12cm
*<12.5cm predicts difficult DTI (considered poor indicator even when used with Mult other assessments)
How big is the flange on a laryngoscope blade?
2 cm
Normal mouth opening?
2-3 FB or 4 cm
Buck teeth may increase the risk of ?
dental damage
Degree of neck flexion and extension decreases by what percent from 16 years of age to 75 years of age?
20%
Neck flexion and extension varies from?
90-165 degrees
What joint provides the highest degree of neck mobility?
AO
What happens when extension is reduced to 23 degrees?
visualization may be difficult
The upper lip bite test is also known as?
ULBT-upper lip bite test= mandibular protrusion test
*valuable assessment tool for difficult airway: problematic oral airway placement, noneffective relief of soft tissue obstruction from poor mandibular mvmt, diff introducing blade into mouth, & obstructive view of glottic opening caused by maldisplacement of the tongue.
What is the purpose of the ULBT?
Assess the mobility of the patients temporomandibular joint function and forward subluxation of the jaw (and assess patients maxillary incissor distance)
Class III ULBT indicates?
lower incisors cannot be moved in line with the upper incisors and cannot bite the upper lip
ULBT is unreliable in what patient population?
edentulous patients
ULBT is best used with what other tests?
increased neck circumference and history of snoring or Modified Mallampati Classification
What 2 factors may make SGA difficult (assessment, condition)
small inter-incisor gap & reductions in atlanto-occipital (AO) joint mvmt (RA or AS).
Obstruction at the level of ______, ______, or below can reduce or completely block ventilation from a SGA device (LMA).
Larynx, Trachea, or Below
When pressures reach _____cm H20 or higher ventilated gases through an SGA device could overcome __________ pressures causing inflation of the stomach, increased in intragastric pressure, & possible risk of vomiting & pulmonary aspiration
25cm H20
esophageal sphincter pressures
What is the absolute contraindication for placement of an emergency cricothyrotomy?
There is NO absolute contraindication
procedures that make performing cricothyrotomy more difficult=
SHORT–> surgery, hematoma, obesity, radiation, tumors/trauma.
CT scans are the gold standard for ruling out what possible complication?
fractures of the cervical spine
CT scans are capable of imaging _____ & ____ whereas MRI can only image _____
soft tissue and bone, soft tissue
Effective preoxygenation can theoretically provide oxygen to the blood for how long in a healthy individual?
12 minutes
Gas flow during preoxygenation should be at least?
5L
Signs of effective preoxygenation?
bag should move w/ I/E
good ETCO2 wave
fraction of expired O2 increases
normal tidal volumes for 3-5 minutes
Fast track preoxygenation is?
pt takes 4 vital capacity breaths in 30 seconds
What is the unanticipated difficiult airway?
airway that is assess as normal and then turns out to not be, no external identifiers indicating difficulty, rare
What is a common cause of an unanticipated difficult airway?
enlarged lymphoid tissue at the base of the tongue
4 ways to maintain airway patency and effect ventilation and thus oxygenation of the tissues?
- mask ventilation w/ appropriate seal
- placement of an SGA
- placement of a tube below the vocal cords
- placement of an invasive airway
Indications of difficult mask ventilation?
- gas flow leaks out of the facemask and increasing use of the 02 flush valve
- poor chest rise
- absent or inadequate breath sounds
- gastric air entry
- poor CO2 return and altered capnographic waveform
- decreasing sat of less than 92%
- necessity to use two handed BMV or oral airway
Difficult laryngoscopy and tracheal intubation is defined as?
inability to visualize any portion of the vocal cords (Cormack & Lehane grade III or IV)
-mult attempts by mult operators indicates difficulty as well
Objective indicators of poor SGA placement are?
leak pressure < 10-15 cm H20 and poor expired tidal volume
Major complications w/ anesthesia occur?
1:22,000
Mortality rate of anesthesia ?
1:180,000
Difficult DL on patients with Mallampati II or III incidence?
1-18%
SGA have a complicaiton rate of?
0.19% largely caused by inadequate seal and failed placement
What is the incidence of failure in patients with Ludwigs angina?
3.8%
Emergency cricothyrotomy occurs?
1:12,500-50,000 cases
What are the 4 end points to the ASA difficult airway algorithm?
- Intubation- awake or asleep
- Facemask or LMA ventilation- adequate or inadequate
- Approach intubation by special means
- Emergency Airway access- surgical or nonsurgical
How does the difficult airway societys algorithim differ from the ASA in LMA use?
DAS recomends LMA as a means for ventilation and oxygenation immediately after failed intubation, if the LMA fails they recomend returning to BMV
The LMA is used at what two points for rescue ventilation in the algorithm?
In anesthetized patient whos trachea cannot be intubated but can be ventilated w/ facemask and the anesthetized patient whose trachea cannot be intubated and whose lungs cannot be conventionally ventilated.
What requirements must be met to define an airway as failed laryngoscopic intubation?
2-4 DL attempts
5-10 minutes total procedure time
Contents of a difficult airway cart?
- standard equipment (ambu, mask, tongue, oral and nasal airways, miller, mac)
- alternative equipment (combitube, stylet, LMA, bougie)
- tube position control (CO2, stethescope)
- Topical anesthetics
- Video Laryngoscope
- Fiberoptic bronchoscopes
Who should be present if an airway is predicted to be difficult?
Additionally anesthesia providers
Primary verification of ETT placement
ETCO2 and BBS
Secondary verificaiton of ETT placement
CXR, bronchoscopic view
Primary goal of airway management?
VENTILATION
What is one benefit of nasal FOI?
often has a direct line to the laryngeal opening however the route may carry an increased risk of hemorrhage or soft tissue damage
Awake intubation would be necessary in what patient population?
pts w/ previous airway difficulty, unstable neck fractures, halo devices, small or limited oral opening, upper airway impingement by mass, and patients in critical care setting
Awake intubation aspiration prophylaxis IV medicaitons?
Bicitra, metoclopramide, H2 blocker
Antisialogues should be given when to maximize the view of laryngeal structures
20 minutes prior
Oxymetolazine comes in what concentration?
0.05%
oxymetolazine (afrin)
When should afrin or phenylephine be given?
2-3 minutes prior to application of local anesthetic
When do lidocaine levels peak?
30 minutes after instillation
What is the most widely used local anesthetic?
Lidocaine
For local anesthesia what is the maximum safe dose of lidocaine
4-5mg/kg
What three nerves need to be anesthetized prior to awake intubation?
Trigeminal, glossopharyngeal, vagus
Anesthetizing the airway via nebulizer prior to awake intubation requires what amount of time?
10-20 minutes
Which produces larger droplets-nebulization or atomization?
Atomization -increase in medication –> denser block
example: DeVilbiss atomizer
technique: pt takes 5-8 deep breaths on atomizer through both mouth and nose
How can the gag & cough reflex be decreased?
anesthetizing the mouth and oropharynx
How much does a half second spray of benzocaine 20% (Hurricaine) deliver?
0.15 mL (30 mg)
1/3 the toxic dose (100mg)
Which is the fastest local anesthetic used in airway management?
Cetacaine
shortened onset & increased duration of action
Methemoglobinemia is associated with the use of what local anesthetic?
Benzocaine
-alternative to use lidocaine 2-4% swish & gargle x 2min
A “lidocaine lollipop” should be held in place for _____to allow adequate coating of the posterior tongue and oropharynx
1-2 minutes
made by coating tip of tongue blade with lidocaine ointment & placing at the back of the tongue
what is the dose of lidocaine used to directly anesthetize the vocal cords?
5ml of 2%Lidocaine
spray on inspiration, coughing indicates deposited on cords.
Glossopharyngeal block is performed at what location?
what size needle?
upon aspiration air is obtained, do what?
upon aspiration blood is obtained, do what?
Dose?
Performed: gutter meets base of palatoglossal arch
Needle: 23 or 25 gauge spinal needle
Air: too deep, withdraw until no air is aspirated
Blood: reposition more medially
Dose: 1-2 ml 2% Lidocaine
5% Intracarotid injection reported, check for symptoms of local anesthetic toxicity after administration
Superior Laryngeal Nerve Block provides dense block of what region?
what membrane is local anesthetic deposited above and through?
What dose deposited above?
What dose deposited through?
Aspiration of Air, what do you do?
Dense block of the supraglottic region
Membrane: Thyrohyoid membrane
Dose Above: 1ml 2% Lidocaine
Dose Below: 2ml 2% Lidocaine (advance 2-3cm through membrane)
Aspirate Air= too deep (pharynx) withdraw & reposition
Transtracheal Block Through what membrane? Is aspiration continuous or intermittent? Needle advanced in what direction? Dose? Aspiration of air, what do you do? When do you inject?
Membrane: Cricothyroid
Aspiration: continuous
Needle is advanced caudal
Dose: 3-5mL 2%Lidocaine
Aspiration of Air: GOOD! in tracheal lumen
Inject: On Inspiration, cause coughing spraying local onto vocal cords.
Cricoid pressure is also known as?
Sellick maneuver
What amount of force is necessary to effectively occlude the esophagus?
30-44 Newtons (N) (20 N prior to LOC, increase to 40 N after LOC)
Maintaining cricoid pressure during active vomitting could result in?
esophageal rupture
True or false-cricoid pressure should be stopped once the tube is visualized going through the vocal cords
False, cricoid should be continued until ETT placement is confirmed by traditional techniques
The combitube is considered what type of device?
infraglottic or retroglottic
*Because ventilation occurs above the glottic opening, the term Supraglottic airway is preferred.
State the 3 indications for LMA
- Rescue ventilation- diff mask ventilation & failed intubation
- Alternative to ETT - in appropriate pts & surgeries
- Conduit to facilitate ETT intubation.
LMA size is based upon?
patient weight Kg
What is the first attempt success rate for LMA placement?
88-95%
5 components of the LMA ProSeal
- larger deeper bowl w/ no grille
- posterior extension of the mask cuff
- gastric drainage tube
- bite block
- anterior pocket for seating an introducer or finger during insertion
LMA ProSeal can accomodate a pressure up to?
30 cm H20
The disposable LMA ProSeal is known as?
LMA supreme
4 components to the LMA fasttrach?
- Anatomically curved rigid airway
- integrated guiding handle
- epiglottic elevating bar
- guiding ramp built into the floor of the mask aperture
Sizes of Fastrach LMA?
3,4,5
what is the C-Trach?
Adds a video screen magnetically mounted to standard Fastrach allowing visualization of the ETT passing through the vocal cords
The cook gas ILA can be re-autoclaved how many times?
40—>stylet not able to be autoclaved but able to be sterilized 10xs
Air-Q device is disposable
Combitube can be considered a secondary rescue device if what else fails?
Intubation, bugie, LMA
King LT is a ______lumen tube
Combitube is a _____ lumen tube
T/F both devices are inserted blindly
King LT is a Single Lumen tube
Combitube is a Double Lumen tube
True-both devices are inserted blindly
The King LT can achieve a ventilatory seal of what pressure?
30cm H20 or higher
This device is reusable! Can be autoclaved up to 50xs
Which suprglottic tube is latex free
King LT
3 benefits of the Trachlite?
- less sore throat
- accomodates anterior airway
- less stimulating
can be used in patients with small mouth openings and minimal neck manipulation
Trachlite confirmation in trachea produces
A Well-defined circumscribed glow noticed below the thyroid prominence & can be readily see on the anterior neck.
Success rate similar to conventional DL
Trachlite may be difficult to place in which patients
Short, thick neck, or redundant tissue
*Not a rescue adjunct for CICV scenario**
Tracheal confirmation of the bougie is evidenced by what?
Stylet bounding along the rings
Eschmann Stylet= Gum Elastic Bougie
How far should a bougie be advanced?
25 cm marked at the lip, advancing too far places the patient at risk for bronchial or distal tracheal puncture
What is one benefit of airway exchange catheters?
Allow gas exchange
- using jet ventilation or 02 insufflation from adapter & bag mask - can be left in difficult airway after extubation in event reintubation is required.
Indications of FOI?
- anticipated difficult airway
- cervical spine immobilization
- anatomic abnormalities of the upper airway
- failed intubation attempt
Limitations of FOI?
- scope can become fogged
- secretions can obstruct view
- use with caution in burns
- very limited in airway trauma
- viewing is limited w/ broken fibers
- use w/ caution in patients w/ epiglotitis
- time consuming
Preparation steps for an awake fiberoptic intubation
- educate pt on what to expect
- antisialagogue
- Anesthetize the Airway
- Adequate sedation
What one piece of equipment must be accessible whenever the FO bronchoscope is used?
Yankauer Suction Device
two types of oral airway guides for the FO scope are:
Williams airway & Ovassapian airway
If view is lost or unsure of FO scope location in airway, you should ?
retract the FO scope until identifiable airway anatomy is visualized.
Instillation of 02 thru suction port aids in oxygenation & keeps optics clear.
FO scope should be advanced until ___.
the Tracheal Rings come into view.
Verify placement by visualization of the carina.
rigid & semirigid FO stylets eliminate
eliminate the need for neck mobility & significant mouth open
A Complication with the use of rigid and semirigid FO stylets & Laryngoscopes is the________
Potential for Airway Trauma
glottic visualization is _____accomplished with a video laryngoscope
A. Directly
B. Indirectly
B. Indirectly
Advantages of VL over DL
- Magnifies airway
- Blade design & Anterior angulation & Video camera improve view
- External monitor- others see airway condition
- Recording capabilities- education, documentation, research
2 Disadvantages of VL
- COST- up to $10,000
2. Blood/Secretions obscure view
Glidescope resembles what blade?
How is it inserted into the mouth & when do you begin to look at LCD monitor?
Resembles the Macintosh blade
-60degree anterior bend, 18mm wide
-camera in middle of blade
Inserted midline, begin viewing LCD monitor as soon as tip of blade is past the teeth.
Placed into vallecula
C-Mac is different from glidescope in it ____
Has a less sharp anterior curve
- facilitates ETT placement - Less effective in difficult "anterior" airways
McGrath power source?
Unique design incorporates?
Does not have _____ that other VL devices do.
One AA battery
1.7inch color LCD is attached to the handle similar anterior angle as glidescope.
Does not have an antifog mechanism
Percutaneous Transtracheal Jet Ventilation what membrane? What insertion direction? Needle size? Who?
Cricothyroid Membrane
Caudad Direction
18g or Ravussin needle or venous or arterial angiocatheter
CICV or reserved for airways with anatomy is less favorable for placement of a surgical cricothyrotomy(<12yo) or as temp means of ventilation
Percutaneous Transtracheal Jet Ventilation (PTJV)
Inspiratory pressure should not exceed ____
usually____ is sufficient
A 1sec inspiration at _____ with rate of 20 delivers ____mL Vt
Inspiratory pressures should not exceed 50psi
25 psi is usually sufficient
A 1sec inspiration at 25psi with a RR rate of 20 delivers 285ml Vt or 5.7L/min ventilation.
PTJV exhalation occurs _______.
what devices can aid exhalation?
I:E ratios to decreased barotrauma?
Exhalation occurs passively
Bilat nasal airways or oral airway facilitate exhalation
I:E ratios of 1:2 or 1:3 decrease barotrauma incidences
Frequent confirmation of Bilat Breath Sounds to rule out pneumothorax or dislodgment of catheter
Retrograde Intubation
When used?
Describe technique
Needle inserted in what direction?
Used: Failed intubation but ventilation possible- not usually used in an emergency (5-7 min procedure)
Technique: 14-18g or Cook needle inserted via cricothyroid membrane in Cephalad direction, confirm air aspiration, Jwire or #2 Mersilene suture passed cephalad into oropharynx, secured wire with clamp at neck, ETT passed over wire into trachea to wire location, wire withdrawn to skin level, ETT advanced further into trachea.
Surgical Cricothyrotomy
Indications
Surgically incising through cricothyroid membrane placing cuffed tracheostomy tube or an ETT
- failed airway CICV
- Traumatic injuries making intubation too difficult or time consuming
- immediate relief of upper airway obstruction
- Need for definitive airway for neck/facial surgery
Absolute contraindication for Surgical Cricothyrotomy
infants & small kids <12yo
larynx small, pliable, & movable makes difficult
instead favor PTJV in this population
Tracheotomy Should the CRNA perform? Damage to what is complication? Should be done in emergency? Done at what Level of the trachea?
CRNA should NOT perform!
Complications: RLN trauma, Large vessel damage
Not performed in emergency!
Level: 4-6th tracheal Ring, below isthmus or thyroid gland
3 reasons for Early Post op Extubation:
- min alteration in Cardiopulmonary physiology
- Decrease risk of Resp infection & complications
- Reduce postop length of stay, decreasing cost & resources
What are the 2 divisions of standard tracheal extubation criteria
- Global
- Respiratory
See Box 22-9 pg 462 for criteria under each
Laryngospasm can be readily elicited during what stage?
Guedel’s Stage II
What 2 pts should be extubated fully awake with full return of airway reflexes?
- Hx of difficult intubation
2. High Risk Aspiration
T/F The development of airway adjuncts (LMA, ILMA, VL) has greatly improved the safety of anesthesia during maintenance, extubation, & recovery
False
-Airway adjunct have ONLY significantly improved the safety of anesthesia induction
3 effective strategies for tracheal extubation in high-risk patients include:
- Extubation over FO
- Extubation followed by supraglottic airway placement
- use of Airway Exchange Catheter (AEC)
* all serve as guides for expedited reintubation in event 02 or ventilation proves inadequate post extubation
* *above techniques improved with judicious use of antisialagogues (robinul) and/or sedative-analgesics (precedex)**
Airway Exchange Catheter
Suggested Adult size?
What activities does this size allow for?
How Long can it be kept in place?
Size: 14 Fr (external diameter)
- critical ETT internal diameter approximates AEC as much as possible to prevent leading edge of ETT from causing trauma/difficult passage.
- Well tolerated & Allows Spontaneous breathing, phonation, & secretion clearance.
- Can be kept in place for up to 72 hrs
- *See box 22-11 pg 463 Benefits of AEC**
Laryngospasm is the ______ protective reflex& contraction of the laryngeal musculature
Occurs as a result of sensory stimulation of the _______ & afferent responses from both the _____ &_______
Laryngospasm is the Involuntary protective reflex
sensory stimulation of the internal branch of the SLN
afferent responses from both the external branch of SLN & the RLN
Two Mechanism of Laryngospasm
intrinsic=
extrinsic=
Laryngospasm results in _______
- “glottis shutter closure”= intrinsic laryngeal muscles mediate vocal cord adduction causing Partial Airway Obstruction
- “ball valve closure”= extrinsic laryngeal muscles cause contraction of False vocal cords & supraglottic soft tissue causing COMPLETE Airway Obstruction
* Laryngospasm results in hypoxia, neg-pressure pulm edema, & cardiovascular derangements
Treatment for Laryngospasm
- 100% 02
- Pos-Pressure Ventilation (10-20cm H20)
- Succs (0.5mg IV or 4-5mg IM)
Laryngotracheobronchitis is also known as _________
Inflammation & Edema occurs _____the level of the vocal cords
2 distinctive respiratory sounds?
Is the adult or pediatric pt more vulnerable ?
Causes?
AKA: Croup
occurs BELOW the level of the vocal cords
sounds: inspiratory&expiratory stridor & Barking Cough
Pediatric pt is more vulnerable to Croup dt narrow caliber of airway
Causes: postintubation edema, mult intubation attempts, too Large ETT, excessive head/neck mvmt
Postop Croup occurs ______
Treatment of croup includes:
Can occure Anytime during postop period, but typically occurs within 3 hrs post extubation
Treatment:
1. humidified 02
2. racemic epinephrine (0.5ml of 2.25% in 2.5ml NS)
3. Dexamethasone (0.1-0.5ml/kg)
4. Other: Helium 02 mixture facilitates 02 delivery thru narrow airways
Complications of Tracheal Intubation
- Airway Trauma
- Aspiration
- Esophageal Intubation
- Endobronchial intubation
- ETT complications
Incidence of sore throat is ______ when blood is observed on instruments.
Pain on swallowing last no more than ____ to ____ hours
sore throat = 40-65%
Pain on swallowing lasts 24-48hours
Trauma to the Larynx 3 subcategories:
- Vocal Cord Paralysis- nerve & mechanical injury
- Granuloma Formation- increased with increased ETT size& duration
- Arytenoid Dislocation & Subluxation- forceful ETT placement
2 Components of Pulmonary Aspiration
- mvmt gastric content from stomach to pharynx
- mvmt gastric content from pharynx to lungs
* *<1/2 of all aspirations lead to pneumonia**
2 phases aspiration pneumonitis?
Managemnt includes?
Phase 1: Direct chemical Injury
Phase 2: Inflammatory mediator release
Management: Pos-Pressure Ventilation & Intensive physiologic support
- chemical destruction of pulm tissue
- Alveolar capillary membrane edema & degeneration
- Alveolar Type 2 pneumocyte destruction
- Microhemmorrhaging leading to hypoxia
3 ways to Minimize risk of gastric aspiration
- Peak airway pressures < 15-20 cm H20 prevent gastric insufflation
- Application cricoid pressure during RSI
- Adherence to NPO guidelines
3 pharmacologic methods to reduce risk of gastric aspiration
- nonparticulate Antacids (bicitra 30ml)= 10-20 min b4 induction – increases gastric pH
- Gastroprokinetic Agent (reglan 10mg IV) = 20-30 min b4 induction –accelerate gastric emptying
- Histamine Blocking agent ( pepcid, cimeidine, ranitidine) 45-60 min b4 induction– increases gastric pH
4 Signs & Symptoms of Endobronchial intubation
- Increased peak pressures
- Asymmetrical chest expansion
- Unilateral breath sounds
- Hypoxemia
The tip of the ETT can move an average of _____cm & up to ____cm toward the carina when the neck is moved from full extension to full flexion.
Average of 3.8cm
Up to 6cm
Withdraw ETT into trachea & hyper-inflate lungs to expand areas of atelectasis
ETT complications can be caused by ______ , _____or ______.
- Mechanical Factors (kinking, biting)
- Foreign Materials (mucus, blood, tissue)
- ETT cuff
Mechanical obstruction can be decreased with the use of this type of ETT.
Wire-reinforced ETT
